sprint consumer access medical plan

Sprint

Consumer Access Medical Plan

Coverage Information Section of

the Summary Plan Description

(Administered by Blue Cross Blue Shield)

2013 Plan Year

What is Inside

Table of Contents

Introduction to Your Consumer Access Plan ..................................... 1

Plan Administration ................................................................... 1

Eligibility & Enrollment .................................................................. 2

How the Plan Works ..................................................................... 2

Deductible ................................................................................ 2 Coinsurance ............................................................................. 3 Your Health Reimbursement Account ........................................... 4 Out-of-Pocket Limit ................................................................... 5 Co-pay..................................................................................... 5

The Network Difference ................................................................. 5

Network Coverage ..................................................................... 5 Example................................................................................... 6 Coverage When Traveling........................................................... 7

Covered Health Expenses .............................................................. 7

What Is a Covered Health Service or Supply? .................................. 8

Definition ................................................................................. 8 Specific Limits, Criteria and Exclusions ....................................... 10

Additional Excluded Services and Supplies ..................................... 24

Filing Claims .............................................................................. 26

Network Benefits ..................................................................... 26 Non-Network Benefits .............................................................. 27

Voluntary Resources – Making the Most of Sprint Benefits ............... 28

BCBS Case Management .......................................................... 28 Sprint Alive! Programs ............................................................. 29

Helpful Numbers and Information ................................................. 30

When Coverage Ends .................................................................. 31

Other Important Information ....................................................... 31

Coordination of Benefits ........................................................... 31 The Plan’s Rights ..................................................................... 34 Legal Information .................................................................... 35

Definitions ................................................................................. 35

This Coverage

Information Section of the

Summary Plan Description (SPD) for your Sprint Consumer Access Medical Plan (Plan or

Consumer Access Plan) has been created using

simple terms in an easy-to-understand

format. This Section will use the terms “we,” “our” or “us” to

refer to Sprint and to “you” or “your” to refer to eligible persons properly

enrolled in this

Plan. Sprint intends to continue the Plan. However, we reserve the right to change

or discontinue the Plan at any time. In case of any conflict with

this SPD, the

Sprint Nextel Welfare Benefits Plan for Employees will control.

Sprint Consumer Access Plan Page 1

2013 Plan Year – Rev. 12/3/2012

Introduction to Your Consumer Access Plan

The Sprint Consumer Access Plan is a consumer-driven health care

plan giving you direct access to a portion of Sprint-funded health care

dollars through a Health Reimbursement Account (HRA) and the

freedom to make choices that align with your needs and values. It

provides a unique approach to pay for preventive care and a safety net

of some coverage for major health care expenses.

The Sprint Consumer Access Plan:

lets you choose your Provider (no referrals required);

provides higher Benefits for Network Providers;

provides an HRA to use toward your portion of Covered Health

Expenses;

pays Benefits after you’ve depleted your HRA and met the

applicable Deductible;

covers qualifying Preventive Services from a Network Provider at

100% without using any of your HRA;

includes coverage for Prescription Drugs; and

offers health resources that help you take greater control over your

and your family’s health care decisions.

The Plan provides Benefits in the form of reimbursement or direct

payment of certain of your and your Covered Dependent’s health care

expenses. Which of your health care expenses and how much of them

are paid or reimbursed by the Plan depends on many factors as

described in this SPD.

Plan Administration

The Plan Administrator has designated a Claims Administrator to

receive, process, and administer benefit claims according to Plan

provisions and to disburse claim payments and payment information.

The Claims Administrators are:

Blue Cross Blue Shield of Illinois (BCBS) for all Benefits except

Prescription Drug Benefits

CVSCaremark, LLC (CVS Caremark) for Prescription Drugs –

Outpatient

You will receive a Member ID card for each administrator: a “Medical

Member ID card” and an “Rx Member ID card.”

The Claims Administrators have established the Plan’s Networks of

Providers, negotiating contract rates for Services and Supplies, by

reviewing Provider credentials, professional standards and accessibility

in your community. To check the Network participation status of your

current Providers, or for claims information, educational materials and

more, visit the applicable Claims Administrator’s web site or call the

number on the back of your applicable Member ID card.

BCBS

www.bsbsil.com

877-284-1571

CVS Caremark

www.caremark.

com

855-848-9165

Please be sure to

read through this entire Medical Plan SPD Coverage Information Section for details

and important information.

http://www.bsbsil.com/

http://www.caremark.com/



2013 Plan Year – Rev. 12/3/2012

Show your Member ID card whenever you visit your Provider. Your

Member ID card contains important information, including the name of

the Plan’s Network. Carry your card at all times, and never lend it to

anyone. If your Member ID card is lost or stolen, please contact the

Claims Administrator.

Eligibility & Enrollment

For rules on who is eligible to be covered, enrollment, and effective

dates of coverage in the Plan, see the separate Eligibility & Enrollment

or Life Events Sections of the SPD incorporated herein by reference on

the Benefits site of i-Connect under Summary Plan Descriptions.

How the Plan Works

Following is the Plan’s structure for payment of Benefits for Covered

Health Expenses.

Deductible

The Deductible is an amount of certain Covered Health Expenses that

must be incurred in a calendar year before the Plan pays its portion of

Coinsurance (“Deductible Expenses”). Deductible Expenses include all

Covered Health Expenses (i.e., not Excluded Health Care Expenses)

except those for Services and Supplies not subject to the Deductible as

described below.

The amounts of the Deductibles are set by Sprint each year and

depend on the coverage category you choose, as well as the type of

expense.

For Covered Health Expenses except Prescription Drugs – Outpatient:

Coverage Category Network Non-Network

Individual $750 $1,500

Family Tiers $1,500 $3,000

For Prescription Drug – Outpatient Covered Health Expenses:

Coverage Category Network Non-Network

Individual $100 $200

Family Tiers $200 $400

The Deductible is not prorated if your coverage becomes effective mid-

year and is adjusted on a non-prorated basis to that for a new

coverage category for mid-year Life Event changes.

Capitalized terms used in this document are defined

here and in the Definitions section. Other capitalized terms are defined in other Sections of the

SPD:

Eligibility and Enrollment, Life Events, and Legal Information.


2013 Plan Year – Rev. 12/3/2012

The Deductible does not have to be met for Preventive, Generic or

Specialty Prescription Drugs, Network Preventive Services or

Supplies, and those Non-Network Preventive Services as described

in the What is a Covered Health Service or Supply Section. But, if

you are enrolled in family coverage, the family Deductible must be

met before the Plan will begin to pay Benefit Levels for any Member.

The Deductible Expenses accumulate over the course of the calendar

year as Claims Administrators process claims and apply toward both

the applicable Network and Non-Network, individual and family,

Deductibles (except that Covered Expenses for Non-Network non-

Preventive Prescription Drugs do not apply to the Prescription Drug

Non-Network Deductible).

However, the Prescription Drug Covered Expenses do not apply

to the Medical Deductible and vice versa.

Coinsurance

Your Coinsurance is the percentage of Covered Health Expenses (i.e.,

not Excluded Health Care Expenses), up to Plan Benefit Limits, after

any applicable Deductible is met, that you are responsible for, up to

the Out-of-Pocket Limit (except for Prescription Drugs – Outpatient).

The Plan pays its Coinsurance, the remaining percentage of Covered

Health Expenses, up to any specified Benefit Limits.

Except as noted in the What is a Covered Health Service or Supply

section, the Coinsurance percentages of Covered Health Expenses

depend on the kind of Service and Supplies and whether they are

Network or Non-Network, as follows:

Provider/Service/Supply

Network Non-Network

You

Pay

Plan

Pays

You

Pay

Plan

Pays

Preventive Services 0% 100% 100%* 0%*

Primary Care Providers 15% 85% 40% 60%

Facilities (except E.R.) 15% 85% 40% 60%

E.R. for Emergency Services 15% 85% 15% 85%

E.R. for Non-Emergency

Services

40% 60% 40% 60%

Prescription Drugs See Prescription Drug Section

Other Supplies 15% 85% 40% 60%

*You pay 40% and Plan Pays 60% for certain Non-Network Preventive

Services as described in the What is a Covered Health Service or

Supply section.

If you incur health care expenses exceeding the Covered Health

Expenses, the amounts you pay are not considered Co-

insurance and thus do not count toward your Deductible or

Out-of-Pocket Limit.


2013 Plan Year – Rev. 12/3/2012

Your Health Reimbursement Account

Unique to the Consumer Access Plan is your Sprint-funded HRA that

you may use to help you meet your portion of Covered Health

Expenses. When the Claims Administrator processes a claim, your

HRA automatically will be used to pay for Covered Health Expenses

before you have to pay any costs – e.g., toward your Deductibles or

Coinsurance.

You are not allowed or required to make any contribution to your HRA.

Instead, each calendar year Sprint allocates a specified sum into an

unfunded HRA within the Plan for you and your Covered Dependents.

This annual allocated amount is determined by Sprint and depends on

the coverage category you choose, as follows:

Coverage Category 2013 HRA Allocation

Individual $300

Family Tiers $600

The annual allocation is pro-rated if your coverage becomes effective

mid-year, increased on a pro-rata basis to that for a larger

coverage category elected at mid-year Life Event changes, and

decreased on a pro-rata basis for mid-year changes to the lower

coverage category.

If you don’t use all of your HRA in a calendar year, and you re-enroll in

the Sprint Consumer Access Plan for the following year, any remaining

HRA balance rolls over into your HRA for the next calendar year, up to

the Out-of-Pocket Limit. In this manner your HRA may “grow” almost

like a savings account. If you don’t re-enroll for the following year,

any remaining HRA balance is forfeited.

The HRA and Your Health Care FSA

You cannot submit an expense to your Health Care Flexible Spending

Account (HC FSA) for reimbursement if that expense is paid or

reimbursed by the HRA or other Plan Benefits.

For example, if your Provider submits a claim for a Covered Health

Expense, those amounts will be deducted from your HRA based on

your balance at the time of Service. You will receive an Explanation of

Benefits showing any additional charges not paid by the HRA (e.g., the

remainder of your Deductible or your Coinsurance). At that time you

can submit those expenses to your HC FSA. You cannot, however,

submit the portion of the Provider’s charges that were already paid by

the HRA, but you may use your HC FSA for portions of a Non-Network

Provider’s charges exceeding the Allowable Amounts.

If your Provider does not submit the claim under this Plan (as in the

case of some Non-Network Providers), you may submit the claim to

the Plan or to your HC FSA, but not both. If you submit it to the Plan

You can keep track of your HRA by going online to www.bcbsil.com, by calling the toll-

free number on the back of your Member ID card or by checking your monthly Member statement sent to you by BCBS.

Reminder:

Flexible Spending Account balances do not

roll over from year to year.

http://www.bcbsil.com/


2013 Plan Year – Rev. 12/3/2012

and only part of the expenses are covered by your HRA or other Plan

Benefits, at that point you may submit the rest to your HC FSA.

Out-of-Pocket Limit

Once your Deductible Expenses and your portion of Coinsurance,

except for Prescription Drugs – Outpatient, in a calendar year reach

the applicable Out-of-Pocket Limit, the Plan pays 100% of Covered

Health Expenses incurred in the rest of the calendar year, up to any

specified Benefit Limits.

The amount of the Out-of-Pocket Limit is set by Sprint and depends on

the coverage category you choose, as follows:

Coverage

Category Network

Non-Network

Individual $2,000 $4,000

Family Tiers $4,000 $8,000

The Out-of-Pocket Limit is not prorated if your coverage becomes

effective mid-year and is adjusted on a non-prorated basis to that for

a new coverage category for mid-year Life Event changes

If you are enrolled in family coverage, the family Out-of-Pocket Limit

must be met before the Plan will begin to pay Benefits at 100% for

any Member.

Your Deductible Expenses and your portion of Co-insurance apply

toward both the Network individual and family Out-of-Pocket Limits

and the Non-Network individual and family Out-of-Pocket Limit.

Co-pay

A Co-pay of $125 is required for Services, whether Emergency or Non-

Emergency, Network or Non-Network, in an Emergency Room. This

Co-pay is not considered for purposes of the Deductible, the Out-of-

Pocket Limit, or your HRA or other Plan Benefits.

A Co-pay is also required for non-Preventive Prescription Drugs –

Outpatient. See Prescription Drugs in the What is a Covered Health

Service or Supply Section. This Co-pay is not considered for purposes

of the Prescription Drug Deductible, your HRA or other Plan Benefits.

The Network Difference

Network Coverage

The Network is an important feature of the Sprint Consumer Access

Plan because the billed charges from a Network Provider are often less

than those from a Non-Network Provider. Also, the Plan generally

pays higher Benefits for Network Covered Services and Supplies after

the Deductible is met. Therefore, in most instances, your HRA will go

further and your Out-of-Pocket expenses will be less if you use a

The Sprint

Consumer Access Plan has a cost-saving national network of health care

Providers, including Pharmacies.

Because your HRA is used to meet some of

your Out-of-Pocket Limit, not all of the Covered Health Expenses paid up to this limit

are actually out of your pocket.


2013 Plan Year – Rev. 12/3/2012

Network Provider than if you use a Non-Network Provider. Plus, with

Network Providers, there are no claim forms to file.

Provider Directory

You may view the Plan Network Provider directory, excluding

Pharmacies, directory online at www.bcbsil.com or by calling BCBS at

the toll-free number on your Medical Member ID card. You may view

the Plan Network Pharmacy directory online at www.caremark.com or

calling CVS Caremark at the toll-free number on your Member Rx ID

Card.

When choosing a Provider, contact both the Provider and the Claims

Administrator to confirm the Provider’s current participation in the

Network at the time of Service or Supply purchase.

Non-Network Coverage

The Plan does give you the flexibility to use Non-Network Providers. If

you choose Services or Supplies outside the Network, however:

the Provider’s charges may be more than the Allowable Amounts,

sometimes significantly higher, which are not Covered Health

Expenses;

the Plan pays no Benefit for Preventive Services (except for Well

Child Care through age 5 and certain Preventive Screenings for

adults);

you have to meet a higher Deductible (except for certain

Preventive Services); and

the Plan pays a lower Benefit Level after the Annual Non-

Network Deductible and in some cases pays no Benefit Level.

Emergency Services received at a Non-Network facility, however, are

covered at the Network Benefit Level.

Example

The following example illustrates how Deductibles, Coinsurance and

Out-of-Pocket Limits vary depending on whether you use a Network or

Non-Network Provider for a Covered Health Service.

Let's say you have individual coverage under the Plan: you have

depleted your HRA and have met your Network Deductible, but not

your Non-Network Deductible, and need to see a Doctor. The flow

chart below shows what happens when you visit a Network Provider

versus a Non-Network Provider.

Network Benefits Non-Network Benefits

| |

1. You go to see a Network

Doctor, and present your

Member ID card.

1. You go to see a non-Network

Doctor, and present your

Member ID card.

| |

Before you receive

care from a Non-Network Provider, you may want to

ask them about the Provider’s billed charges and compare them to Allowable Amounts for those Services or

Supplies. For

Allowable Amounts, call the applicable Claims Administrator.




2013 Plan Year – Rev. 12/3/2012

2. You receive treatment from

the Doctor. The Allowable

Amount for your office visit

is the Network rate of $125.

2. You receive treatment from

the Doctor. The Allowable

Amount for your office visit is

$175; however, the Doctor’s

fee is $225.

|

|

3. Since the Network

Deductible has been met,

the Plan pays Coinsurance;

Network Doctors’ office

visits are covered at 80%,

so BCBS pays $100 (80% x

$125).

3. Since the Non-Network

Deductible has not been met

you are responsible for paying

the Allowable Amount of $175;

in addition the Doctor may bill

you for his entire fee of $225.

| |

4. You pay Coinsurance of the

remaining 20% of the

Allowable Amount, or $25

[20% x $125]. $25 is also

applied to your Out-of-

Pocket Limit.

4. You receive a bill from the

Doctor, and pay the Doctor

directly. You then submit your

receipt and completed claim

form to the address on the

back of your Member ID card.

| 5. $175 (Allowable Amount) is

credited toward your Non-

Network Deductible and Out-

of-Pocket Limit; any remaining

amount the Doctor billed and

you paid (e.g., $50) does not

get credited to either.

Coverage When Traveling

When you are away from home within the United States, your Plan

coverage travels with you. Check with the Claims Administrator for

the Network Provider Directory.

The Network does not extend internationally; however, Emergency

Services and Supplies by Non-Network Providers, including

international Providers, are covered at the Network level. Non-

Emergency Services outside the United States are Excluded Health

Services.

Covered Health Expenses

For purposes of Benefits payable or reimbursable under this Plan,

Covered Health Expenses are charges by a Provider (who is not also

the Patient) that are:

directly related to Covered Health Services and Supplies – not

to Excluded Health Services or Supplies – that:


2013 Plan Year – Rev. 12/3/2012

o are provided to a Member while properly enrolled in and

covered under this Plan; and

o meet all other requirements under the Plan as described in this

Coverage Information Section; and

not Excluded Health Care Expenses.

Excluded Health Care Expenses, which are not considered for

purposes of the Deductible or Out-of-Pocket Limit, your HRA or other

Plan Benefits, are those charges:

greater than the Allowable Amount or Plan Benefit Limits

(except limits related to the DAW, Step Therapy or 90-Day Fill

Penalties – see Prescription Drugs - Outpatient);

equal to the amount of any applicable E/R Co-pay;

that would not ordinarily be made in the absence of coverage by

this Plan;

for missed appointments; room or facility reservations; completion

of claim forms; record processing; or Services or Supplies that are

advertised by the Provider as free;

prohibited by anti-kickback or self-referral statutes;

which the Patient is not legally required to pay, including charges

paid or payable by the local, state or federal government (for

example Medicare), whether or not payment or benefits are

received, except as provided in this SPD (e.g., see the Medicare

and this Plan section); and

Services that are not coordinated through a Network Provider or

Pharmacy if the Claims Administrator has determined that you

were using health care Services or Prescription Drugs in a harmful

or abusive manner (which Network Provider or Pharmacy you may

select within 31 days of being notified by the Claims Administrator

to do so or which otherwise the Claims Administrator will select for

you).

What Is a Covered Health Service or Supply?

Definition

Covered Health Services and Supplies are Services and Supplies,

which, subject to the rest of this section, are:

rendered by or pursuant to and consistent with the directions,

orders or prescription of a Doctor or Dentist and, except as noted

below, in a facility that is appropriate for the Service or Supply

and the Patient’s Illness or Injury;

Medically Necessary (including Preventive Services as noted);

and

not Excluded Health Services and Supplies.

Examples of Supplies or Services that could be Covered, subject to

Specific Limits, Criteria and Exclusions below, are:

The important thing to remember is that

Network

Providers may not charge more than the Allowable Amounts because

of their agreement to be in the Network.


2013 Plan Year – Rev. 12/3/2012

Provider consultations (including second or third opinions) and

exams, screenings (e.g., vision, hearing), and other diagnostics

(lab, x-rays, imaging, biopsies, scopic procedures (such as

arthroscopy, laparoscopy, bronchoscopy and hysteroscopy),

cultures, etc.) in Provider’s office, Hospital or Alternate Facility;

Local and air ambulance and treatment at a Hospital Emergency

Room or Alternate Facility, including an Urgent Care Center;

Injections, chemo/radio therapy, dialysis, acupuncture, chiropractic

and other therapeutic treatments;

Surgeries at a Hospital or Alternate Facility, inpatient or outpatient,

including:

o pre- and post-operative care and related Doctor Services and

Supplies (radiology, pathology and anesthesiology); and

o room and board for Inpatient care and related facility Services

and Supplies;

Prescription Drugs;

External Prostheses and other Durable Medical Equipment and

certain Disposable Supplies; and

Skilled Nursing and Rehabilitation Services, including physical,

occupational, speech, and cognitive therapies, osteopathic

manipulation, pulmonary rehabilitation and cardiac rehabilitation;

and

Home Health Care, Private Duty Nursing, and Hospice Care

Services.

Sprint has delegated to the Claims Administrators the discretion and

authority to decide whether a Service or Supply is a Covered Health

Service or Supply. Where this SPD is silent, the Plan is administered

according to the Claims Administrators’ standard coverage policies and

standard guidelines.

It is strongly recommended that you seek Pre-Authorization for

certain health care Services and Supplies, including but not

limited to the following:

All Non-Network Services and Supplies, including but not limited to

Home Health Care, Hospice Care, Private Duty Nursing, Mental

Health Services, Reconstructive Services and Prosthetic Devices;

and

Cancer, Transplant, or Reconstructive Services and Supplies,

whether Network or Non-Network.

For All Pre-Authorizations Call…

MEDICAL

(BCBS)

PRESCRIPTION DRUG

(CVS Caremark)


2013 Plan Year – Rev. 12/3/2012

In most cases your Provider will take care of obtaining Pre-

authorization; however, it is recommended that you be sure that

pre-authorization has been requested and received.

After receiving a pre-authorization request, using established medical

guidelines, the Claims Administrator will determine the Medical

Necessity of an Admission (including its length), other Service or

Supply and whether other Limits, Criteria or Exclusions apply.

Specific Limits, Criteria and Exclusions

Following are, for certain Medical Conditions and Services or Supplies:

specific criteria that must be met for certain Services or Supplies

to be Covered;

specifically excluded Services or Supplies, regardless of

otherwise meeting the definition of Covered Health Services and

Supplies; and

specific Benefit Limits for certain Medical Conditions or Services

or Supplies.

Please keep in mind that Medical Necessity is paramount in

the Claims Administrator’s determination of whether any of

the following Services or Supplies is Covered.

Acupuncture & Chiropractic Services

Benefit Limit:

$500 per calendar year Network and Non-Network combined, for all

Services combined

Criteria for Coverage:

Services must be performed in an office setting by a Doctor or an

acupuncturist/chiropractor, as applicable, practicing within the

scope of his/her license or certification.

Services must be therapeutic and more than to maintain a level of

functioning or prevent a Medical Condition from occurring or

recurring.

Ambulance

Criteria for Coverage of Local Ambulance: Must be:

for Emergency only, except

o from a Non-Network Hospital or Alternate Facility to a Network

Hospital,

o to a Hospital that provides a higher level of care,

o to a more cost-effective acute care facility, or

877-284-1571

8 a.m. - 6 p.m.

Monday – Friday

www.bcbsil.com

855-848-9165

(24/7)

www.caremark.com

Please refer back

to the Coinsurance section beginning

on page 3 for the Plan’s Benefit Level – after the

Deductible, except as noted – for Covered Health Expenses, subject to any Benefit Limits

stated in this section.




2013 Plan Year – Rev. 12/3/2012

o from an acute care facility to a sub-acute setting; and

by a licensed ambulance service and to the nearest Hospital that

offers Emergency Services.

Criteria for Coverage of Air Ambulance:

must be for Emergency only;

ground transportation must be impossible or would put Member’s

life or health in serious jeopardy; and

must be to the nearest (in the absence of special circumstances as

approved by BCBS) facility where the needed medical Emergency

Services can be provided.

Chiropractic Services – see Acupuncture & Chiropractic Services

Dental Services – Generally Excluded

Dental Services and Supplies are excluded, even if Medically

Necessary, except for Accidental Injury or Limited Medical Conditions,

as described below.

Accidental Injury

Covers only, except as included under Reconstructive Services, the

following Dental Services and Supplies for and directly related to

damage to a sound, natural tooth resulting from to Accidental

Injury (i.e., not as a result of normal activities of daily living or

extraordinary use of the teeth): Emergency examination,

diagnostics, endodontics, temporary splinting of teeth,

prefabricated post and core, simple minimal restorative procedures

(fillings), extractions, post-traumatic crowns if the only clinically

acceptable treatment, replacement of teeth lost due to the

Accidental Injury by implant, dentures or bridges (but excluding

repairs to bridges and crowns).


the Dentist certifies that the damaged tooth was virgin and

unrestored and that it:

o had no decay;

o had no filling on more than two surfaces;

o had no gum disease associated with bone loss;

o had no root canal therapy; and

o functioned normally in chewing and speech;

initial contact with a Doctor or Dentist regarding damage

occurred within 72 hours (or later as extended by and upon

request to BCBS) of the Accidental Injury;

Services for final treatment to repair the damage are started

within three months (or later as extended by and upon request

to BCBS) and completed within 12 months of the Injury; and

Services are received from a Dentist (or Doctor as needed for

Emergency treatment).

Limited Medical Conditions

The Exclusion for Dental care is broad: examples include treatment of congenitally missing, mal-positioned, or

extra teeth, and

treatment of dental caries resulting from dry mouth after radiation or as a

result of medication. See your Dental plan for possible coverage.


2013 Plan Year – Rev. 12/3/2012

Covers only except as included under Reconstructive Services,

diagnostic, restorative (basic and major restorative), endodontic,

periodontic, and prosthodontic Services (1) for cancer or cleft

palate; and (2) related to transplant preparation and use of

immunosuppressives (does not include prosthodontics).

Includes excision of lesions or tumors, unless for removal of tori,

exostoses, fibrous tuberosity (such as preparation for dentures) or

for periodontal abscess, or endodontic cyst.

Disposable Medical Supplies

Covers only Supplies that are:

provided incident to Services in a Hospital or Alternate Facility or

Home Health Care;

used in conjunction with Durable Medical Equipment (such as

oxygen, tubings nasal cannulas, connectors and masks); or

the following ostomy supplies: pouches, face plates, belts,

irrigation sleeves, bags and catheters, and skin barriers.

Excludes: artificial aids including but not limited to elastic or

compression stockings, garter belts, corsets, ace bandages, urinary

catheters, and diabetic supplies covered as a Prescription Drug (such

as blood glucose monitors, insulin syringes and needles, test strips,

tablets and lancets), deodorants, filters lubricants, appliance cleaners,

tape, adhesive, tape or adhesive remover and any other Disposable

Medical Supply not specifically listed as included above.

Durable Medical Equipment (DME)

Benefit Limit:

One speech aid device and tracheo-esophageal voice device Lifetime

Maximum.

Covers only:

the most cost-effective alternative piece of one single unit of DME

to meet your functional needs (example: one insulin pump);

repairs if required to make the item/device serviceable and the

estimated repair expense does not exceed the cost of purchasing

or renting another item/device;

replacement of essential accessories, such as hoses, tubes, mouth

pieces, etc.; and

replacement only for damage beyond repair with normal wear and

tear, when repair costs exceed new purchase price, or due to a

change in your Medical Condition.

Excludes repairs or replacement if lost or stolen or damaged due to

misuse, malicious breakage or gross neglect.


DME must be ordered or provided by a Doctor for Outpatient use;

and

A preliminary three-month rental period for speech aid devices and

tracheo-esophageal voice devices is required.


2013 Plan Year – Rev. 12/3/2012

Emergency Room Services

“Emergency” is defined in the Definitions section. Use of

Emergency Room Services for a Non-Emergency results in

Non-Network Level Plan Benefits, even at a Network facility.

Co-pay for Emergency Room: $125

Family Planning Services

Excludes tubal ligation and vasectomy reversals.

Genetic Services

Benefit Limit:

Genetic counseling limited to three visits per calendar year for both

pre- and post-genetic testing.

Covers only a proven testing method for identification of genetically-

linked inheritable disease and genetic counseling.

Criteria for coverage generally:

the Member has symptoms or signs of a genetically-linked

inheritable disease;

it has been determined that a person is at risk for carrier status as

supported by existing peer-reviewed, evidence-based, scientific

literature for the development of a genetically-linked inheritable

disease when the results will impact clinical outcome; or

the therapeutic purpose is to identify specific genetic mutation that

has been demonstrated in the existing peer-reviewed, evidence-

based, scientific literature to directly impact treatment options.

Criteria for coverage of embryo genetic testing prior to implantation:

Either donor has an inherited disease or is a documented carrier of a

genetically-linked inheritable disease.

Criteria for coverage of genetic counseling: Member must be

undergoing approved genetic testing or have an inherited disease and

is a potential candidate for genetic testing.

Hearing Care Services and Supplies

Benefit Limits:

Network – hearing aids (electronic amplifying devices designed to

bring sound more effectively into the ear consisting of a microphone,

amplifier and receiver): 100% up to $600 both ears every 24 months;

all other Services: 80%

Non-Network – Exam and fitting of hearing aids only

Covers only;

routine hearing screenings and exams when associated with an

evaluation for a hearing aid by a Provider in the Provider’s office;


2013 Plan Year – Rev. 12/3/2012

hearing aids required for the correction of a hearing impairment (a

reduction in the ability to perceive sound that may range from

slight to complete deafness) and associated fitting and testing; and

cochlear implant or bone anchored implant (subject to below) and

Surgery to implant.

Criteria for coverage:

Hearing aid and implant covers only as described under Durable

Medical Equipment.

For bone anchored implants: You must have either of the following:

o craniofacial anomalies and abnormal or absent ear canals that

preclude the use of a wearable hearing aid; or

o hearing loss of sufficient severity that it would not be

adequately remedied by a wearable hearing aid.

Home Health Care Services

Benefit Limits:

Non-Network – 60 visits (of any duration) per calendar year (Network

and Non-Network visits cross apply)

Criteria for coverage: Must be:

ordered and supervised by a Physician;

when Skilled Care is required either:

o fewer than seven days each week; or

o fewer than eight hours each day for periods of 21 days or less;

and

provided in your home by a Registered Nurse, or by either a home

health aide or Licensed Practical Nurse and supervised by a

Registered Nurse.

Hospice Care

Benefit Limits:

After Member’s death, only 3 counseling sessions, for up to 12

months.

Non-Network – $5,000 per event


Member must be diagnosed with terminal Illness (expected to live

six or less months), as certified by an Attending Doctor who

recommended the Hospice Care;

Hospice Care must be received from a licensed hospice agency,

which can include a Hospital; and

Except for post-death bereavement, charges must be incurred

within six months after the certification or recertification (required

if Member still living after six months from prior certification) of

terminal Illness.

Infertility Services

Covers only diagnostic office visits, at 100%.

With Home Health Care, you can recuperate in

the comfort of your home as an alternative to prolonged Hospital confinement.


2013 Plan Year – Rev. 12/3/2012

Inpatient Stay

For all Inpatient Stays, covers only up to cost of semi-private room,

unless no semi-private rooms are available or if a private room is

necessary according to generally accepted medical practice.

Maternity Services

Expectant mothers are asked to call SprintAlive! at 866-90-

ALIVE (25483) before the end of their first trimester.

Includes:

prenatal care, delivery, postnatal care and any related

complications;

midwife visit to confirm pregnancy and all subsequent visits; and

Inpatient Stays for mother and newborn in Hospital or Network

birthing center of up to 48 hours following vaginal delivery and up

to 96 hours following cesarean section delivery.;

Any Inpatient Stay for the baby longer than the mother’s is

subject to the baby being a Covered Dependent under the

Plan – see Eligibility and Enrollment Section of the SPD

incorporated herein by reference on the Benefits site of i-

Connect under Summary Plan Descriptions) – and a separate

Deductible and Coinsurance.

Remember, you must notify the EHL (ehlticket or 800-697-

6000) within 30 calendar days after the birth to add your

newborn as a Covered Dependent.

Excludes home birthing or doula Services or Supplies.

Mental Health/Substance Use Disorder Services

Includes inpatient (Hospital or Alternate Facility) and outpatient

(Provider’s office or Alternate Facility):

diagnostic evaluations and assessment;

treatment planning;

referral Services;

medication management and other psychiatric Services;

individual, family, therapeutic group and Provider-based case

management Services and therapy;

crisis intervention;

detoxification (sub-acute/non-medical); and

Transitional Care.

Transitional Care means Mental Health Services/Substance Use

Disorder Services that are provided through transitional living facilities,

group homes and supervised apartments that provide 24-hour

supervision that are either:

sober living arrangements such as drug-free housing, alcohol/drug

halfway houses. These are transitional, supervised living

Amniocentesis, ultrasound, or any other

procedures requested solely for sex determination of a fetus generally

not considered Medically

Necessary except to determine the existence of a sex-linked genetic disorder.


2013 Plan Year – Rev. 12/3/2012

arrangements that provide stable and safe housing, an

alcohol/drug-free environment and support for recovery. A sober

living arrangement may be utilized as an adjunct to ambulatory

treatment when treatment doesn't offer the intensity and structure

needed to assist the Patient with recovery.

supervised living arrangements that are residences such as

transitional living facilities, group homes and supervised

apartments that provide Members with stable and safe housing and

the opportunity to learn how to manage their activities of daily

living. Supervised living arrangements may be utilized as an

adjunct to treatment when treatment doesn't offer the intensity

and structure needed to assist the Patient with recovery.

Excludes:

Services performed in connection with conditions not classified in

the current edition of the Diagnostic and Statistical Manual of the

American Psychiatric Association;

Services or Supplies for the diagnosis or treatment of Mental

Illness, or Substance Use Disorders that, in the reasonable

judgment of the Mental Health/Substance Use Disorder

Administrator, are not:

o consistent with the Mental Health/Substance Use Disorder

Administrator’s level of care guidelines or best practices as

modified from time to time; or

o clinically appropriate for the Patient’s Mental Illness/Substance

Use Disorder based on generally accepted standards of medical

practice and benchmarks;

Mental Health Services as treatments for V-code conditions as

listed within the current edition of the Diagnostic and Statistical

Manual of the American Psychiatric Association;

Mental Health Services as treatment for a primary diagnosis of

insomnia and other sleep disorders, feeding disorders, neurological

disorders and other disorders with a known physical basis;

Treatments for the primary diagnoses of learning disabilities,

conduct and impulse control disorders, personality disorders and

paraphilias (sexual behavior that is considered deviant or

abnormal);

Educational/behavioral services that are focused on primarily

building skills and capabilities in communication, social interaction

and learning;

Tuition for or services that are school-based for children and

adolescents under the Individuals with Disabilities Education Act;

Learning, motor skills and primary communication disorders as

defined in the current edition of the Diagnostic and Statistical

Manual of the American Psychiatric Association;

Mental retardation as a primary diagnosis defined in the current

edition of the Diagnostic and Statistical Manual of the American

Psychiatric Association;

methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-

Methadol), Cyclazocine, or their equivalents for drug addiction; and

intensive behavioral therapies such as applied behavioral analysis

for Autism Spectrum Disorders (a group of neurobiological

disorders that includes Autistic Disorder, Rhett's Syndrome,

Asperger's Disorder, Childhood Disintegrated Disorder, and


2013 Plan Year – Rev. 12/3/2012

Pervasive Development Disorders Not Otherwise Specified

(PDDNOS).


Services must be coordinated, authorized and overseen by BCBS’s

Mental Health/Substance Use Disorder Administrator:

Semi-private room only.

Criteria for coverage of psychiatric Services for Autism Spectrum

Disorders: Services must be provided by or under the direction of an

experienced psychiatrist and/or an experienced licensed psychiatric

Provider and focused on treating maladaptive/stereotypic behaviors

that are posing danger to self, others and property and impairment in

daily functioning.

Criteria for Coverage of Special Programs:

Special programs for the treatment of your Substance Use Disorder

that may not otherwise be covered under this Plan require referral to

such programs through the Mental Health/Substance Use Disorder

Administrator, who is responsible for coordinating your care or through

other pathways as described in the program introductions. Any

decision to participate in such program or service is at the discretion of

the Member and is not mandatory.

Nutritional Services

Covers only an individual session with a registered dietician.


Member must have an Illness that requires a special diet, such as,

diabetes mellitus, coronary artery disease, congestive heart failure,

severe obstructive airway disease, gout, renal failure, phenylketonuria

(a genetic disorder diagnosed at infancy), and hyperlipidemia (excess

of fatty substance use disorders in the blood).

Excludes:

all other individual or group nutritional counseling;

nutritional or cosmetic therapy using high dose or mega quantities

of vitamins, minerals or elements, and other nutrition therapy;

food of any kind; and

health education classes unless offered by BCBS, such as asthma,

smoking cessation and weight control classes.

Organ or Tissue Transplant Services

Benefit Limit: Non-Network – 0%

Examples include autologous bone marrow/stem cell, cornea, heart,

lung, kidney, pancreas, liver.

Includes:

compatibility testing undertaken prior to procurement;

obtaining the organ and tissue (removing, preserving and

transporting the donated part);

Some transplants might be considered

Cosmetic/not Medically Necessary or

Experimental or Investigational, such as hair transplants. Pre-Authorization is recommended.


2013 Plan Year – Rev. 12/3/2012

Hospitalization and Surgery for live donor;

rental of wheelchairs, hospital-type beds and mechanical

equipment required to treat respiratory impairment.


Services must be ordered by a Network Provider; and

except for cornea transplants, Services must be performed at a

COE if available within 150 miles of Patient’s permanent residence,

or a Network facility if there is no COE available within 150 miles of

the Patient’s permanent residence.

Pharmaceutical Products

Covers: Pharmaceutical Products not typically available by prescription

at a pharmacy, and their administration, including:

allergy immunotherapy, oncology (radiation or intravenous

chemotherapy) and rheumatology;

antibiotics; and

inhaled medication in an Urgent Care Center for treatment of an

asthma attack.


Must be administered or supervised by Doctor within the scope of the

provider's license on an outpatient basis only in a Hospital,

Alternate Facility, Doctor’s office or in the Patient’s home.

Podiatry Services and Supplies

Routine Foot Care for the treatment of diabetes or peripheral

vascular disease may be Medically Necessary, but other Routine

Foot Care seldom is Medically Necessary.

Also, foot orthotics such as arch supports, inserts or additions

and orthopedic shoes are usually considered Cosmetic, and

thus, are Excluded Supplies, but may be Medically Necessary

for certain Medical Conditions such as diabetes.

Routine Foot Care includes cleaning and soaking of feet and the

application of skin creams (unless foot-localized Illness or Injury or in

the case of risk of neurological or vascular disease arising from

diseases such as diabetes); nail trimming and cutting, debriding

(removal of dead skin or underlying tissue); treatment of toe nail

fungus, flat and subluxation of feet, superficial lesions of the feet, such

as corns, callouses and hyperkeratosis; arch supports, shoe inserts,

shoes, lifts, wedges, and orthotics.

Prescription Drugs – Outpatient

For Inpatient Stays, Prescription Drugs would be covered as any other

Supply in the course of the applicable Inpatient Stay. The remainder of

this section applies to Prescription Drugs for Outpatient use.

Preventive Prescription Drugs are not subject to the Deductible. Non-

Network, non-Preventive Prescription Drugs do not apply to the


2013 Plan Year – Rev. 12/3/2012

Prescription Drug Non-Network Deductible and Prescription Drug Non-

Network Out-of-Pocket Maximum.

Benefit is the Allowable Amount, subject to Benefit Limits below, less

Member Co-pay or Co-insurance subject to a Dollar Maximum. These

amounts depend on whether the drug is:

Generic, Preferred Brand-name (PDL Brand), Non-preferred

Brand-name (Non-PDL Brand) or Specialty; and

dispensed Network or Non-Network Retail up to a 30-day

supply; Mail Order supply; or Retail up to 90-day supply (Retail

90).

Co-pay and/or Co-insurance amounts are as follows: Network Non-

Network Retail 30 Mail Order Retail 90

Generic: Co-pay* $5 $10 $15 $20

PDL Brand: Co-insurance/$Max

20%/$100 15%/$150 20%/$150 30%/$150

Non-PDL Brand: Co-insurance/$Max

25%/$175 20%/$200 $25%/$200 30%/$200

Specialty Drug Co-pay – $100 ($175 for Non-PDL Brand-name)*

*or Allowable Amount, if less.

Benefit Limits for Non-Preventive Prescription Drugs:

Allowable Amount of:

o except if Step Therapy Requirement applies, the generic

Therapeutically Equivalent Prescription Drug (“DAW

Penalty”); and

o up to 30-day supply, 90-day supply under 90-day Fill

Requirement, or applicable Supply Limit, as applicable;

0% if any Step Therapy Requirement (“Step Therapy Penalty”) or

90-Day Fill Requirement (“90-Day Fill Penalty) is not met.

0% for unit-dose packaged Prescription Drugs.

Appetite Suppression and Weight Control - 50% Network or Non-

Network.


Must be dispensed pursuant to a Doctor’s written prescription.

If a Specialty Drug, Patient must be enrolled in Specialty Program.

Prescription must specify the number of refills, be limited to

number of refills under accepted medical practice standards, and

be less than one year old at the time of dispensing unless

otherwise permitted by applicable law.

Supply Limit means CVS Caremark’s restriction on the amount of a

Prescription Drug dispensed per prescription order or refill.

Managed Condition means a Medical Condition that requires

maintenance medications to treat it, such as diabetes, glaucoma,

blood pressure/heart disease, high cholesterol and hormone

deficiencies.

Visit

www.caremark.com

or call the toll-free number on your Rx Member ID card to determine if a

Prescription Drug is on the PDL or subject to a Supply Limit, participation in Specialty Program or Step Therapy or 90-day

Fill requirement.



2013 Plan Year – Rev. 12/3/2012

90-Day Fill Requirement means the requirement to have a

prescription for a 90-day supply, where allowed by law, following

an initial 30-day supply and one 30-day refill, of a Prescription

Drug for a Managed Condition. Requirement may be met through

Mail Order Service or Retail 90 Pharmacies. To maximize your

benefit, ask your Doctor to write your prescription for a 90-day

supply, with refills when appropriate, not a 30-day supply with two

refills.

Step Therapy Requirement means the requirement to use a lower

tier Prescription Drug (or “first-line therapy”) for 30 days before

use of a higher tier Prescription Drug for certain drugs including,

but not limited to ACE inhibitors, benign prostatic hyperplasia

(BPH) treatment, oral bisphosphonates, COX-2 inhibitors, DPP-4

Inhibitors, leukotriene inhibitors, long acting β-agonists (LABA),

pregabalin, selective serotonin reuptake inhibitors (SSRIs), statins

and atomoxetine.

Specialty Prescription Drug means Prescription Drug that is

generally high cost, self-injectable biotechnology drug used to treat

patients with certain Medical Conditions such as multiple sclerosis

(e.g., Avonex, Betaseron), cystic fibrosis (e.g., Pulmozyme, Tobi),

and growth hormone deficiency (e.g., Genotropin, Humatrope).

Specialty Program means the CVS Caremark program providing

expert Prescription Drug therapy management services for

Specialty Prescription Drugs. Contact CVS Caremark at the number

on your Rx Member ID card to enroll.

Excludes:

oral non-sedating antihistamines or a combination of

antihistamines and decongestants;

anti-ulcer medications in the Protein-Pump inhibitor (PPI)

therapeutic class;

Prescription Drugs that:

o are available, or are comprised of components that are

available, in a Therapeutically Equivalent over-the-counter

form;

o replace a Prescription Drug that was lost, stolen, broken or

destroyed; or

o are provided following a Member’s Medicare-eligibility; and

vitamins, minerals, and food, dietary and nutritional supplements,

except prenatal vitamins, vitamins with fluoride, and single entity

vitamins pursuant to a prescription, or prescribed to maintain

sufficient nutrients to maintain weight and strength equal to the Patient’s overall health status.

Preventive Services

Network Benefit: 100%

See the Definitions Section for the list of all Preventive Services.

Insulin, Imitrex, epinephrine, and glucagon are not considered Specialty

Prescription Drugs. Access a complete list of Specialty Prescription

Drugs through the Internet at

www.caremark. com or by calling the number on the back of your Rx Member ID card.


2013 Plan Year – Rev. 12/3/2012

Benefit Limit:

Non-Network – 0%, except for only:

prostate exam for males age 40 and over (once a year);

breast cancer screening with mammography – with or without

clinical breast examination, every 1-2 years for women age 40

years and older;

pap smear (but not routine exam);

colorectal screening for average risk males and/or females age 50

and over, which includes:

o colonoscopy (covered every 10 years);

o Double Contrast Barium Enema –DCBE (every 5 years); and

o sigmoidoscopy (every 5 years);

cardiovascular/cholesterol screenings (for age 20 and above; every

5 years);

osteoporosis (for women age 65 or older or for women at age 60

that are high risk); and

well child services:

o circumcision, medical examinations and tests, and

immunizations through age five; and

o eight exams during the first 18 months of the baby’s life and

four exams through age five.

Private Duty Nursing

Covers only outpatient Private Duty Nursing care given on an

outpatient basis only by a Registered Nurse, Licensed Practical Nurse

or Licensed Vocational Nurse.

Prosthetic Devices – see also Hearing Services and Supplies (for bone

anchored implants)

Benefit Limits:

Network – $7,500 Maximum for purchase, repair and replacement,

including Non-Network Benefits, every 24 months

Non-Network – $1,000 Maximum every 24 months

Covers only:

the most cost-effective alternative piece of one single device to

meet your functional needs;

repairs if required to make the item/device serviceable and the

estimated repair expense does not exceed the cost of purchasing

or renting another item/device; and

replacement only for damage beyond repair with normal wear and

tear, when repair costs exceed new purchase price, or due to a

change in your Medical Condition.


Must be ordered or provided by a Doctor for Outpatient use.

Must be following mastectomy for breast prosthesis.

Radiotherapy (e.g., radiation) – see Pharmaceutical Products

Reconstructive Services


2013 Plan Year – Rev. 12/3/2012

Includes: breast reconstruction following a mastectomy, reconstruction

of the non-affected breast to achieve symmetry and replacement of

existing breast implant if initial breast implant followed mastectomy

and other Services and Supplies required by the Women’s Health and

Cancer Rights Act of 1998, such as treatment of complications.

Criteria for Coverage: Patient has a physical impairment and the

primary purpose of the procedure is Reconstructive.

Criteria for Coverage of Orthognathic Surgery: must be for the

treatment of:

maxillary and/or mandibular facial skeletal deformities

associated with masticatory malocclusion (specific

anteroposterior, vertical, transverse discrepancies and

asymmetries), facial trauma, syndromes such as Apert or

Crouzon, facial clefts, neoplasms, surgical resection, iatrogenic

radiation; or

facial skeletal anomaly of either the maxilla or mandible that

demonstrates a functional medical impairment such as:

o inability to incise solid foods;

o choking on incompletely masticated solid foods;

o damage to soft tissue during mastication;

o malnutrition and weight loss due to inadequate intake

secondary to the jaw deformity; or

o documented speech impairment, sleep apnea, airway

defects, soft tissue discrepancies or temporomandibular

joint pathology.

Reconstructive means where the expected outcome is physiologic

restoration or improvement of a physical impairment – i.e., the

targeted body part is made to work better – not just relieving

psychological suffering as a result of the impairment.

Rehabilitation Facility Services – see Skilled Nursing and

Rehabilitation Facility Services – Outpatient

Rehabilitation Services

Benefit Limit:

Maximum 60 visits/days per Member per calendar year for

physical, occupational, cognitive and speech therapy combined.

Maximum $2,500/calendar year for Developmental Speech Therapy

(up to age 7)

Includes physical, occupational, speech, cognitive, osteopathic,

pulmonary and cardiac therapy.

Excludes:

when part of authorized Home Health Care, except as provided

under Home Health Care Services;

at BCBS’s discretion, Rehabilitation Services that are not expected

to result in significant physical improvement in Member’s condition

within two months of the start of treatment or if treatment ceases

to be therapeutic and is instead administered to maintain a level of


2013 Plan Year – Rev. 12/3/2012

functioning or to prevent a Medical Condition from occurring or

recurring.

Criteria for Coverage: Services must be provided by a licensed therapy

Provider under the direction of a Doctor.

Criteria for Coverage of speech therapy: the speech impediment or

dysfunction must have resulted from Injury, Illness, stroke or a

Congenital Anomaly, is developmental in nature up to age 7, or is

needed following the placement of a cochlear implant

Skilled Nursing and Rehabilitation Facility Services – Outpatient

Benefit Limit:

90-day Maximum per Member per calendar year Network/Non-Network

combined (both Skilled Nursing and Rehabilitation)


Must be needed because:

o the Medical Condition requires intensity of care less than that

provided at a Hospital but greater than that available in a home

setting; or

o a combination of Skilled Nursing and Rehabilitation Services are

needed on a daily basis or if Medical Condition would have

otherwise required an Inpatient Stay in a Hospital; and

you are expected to improve to a predictable level of recovery.

Spinal Services – see Acupuncture & Chiropractic Service

Substance Use Disorder Services – see Mental Health/Substance Use

Disorder Services

Temporomandibular Joint Dysfunction (TMJ) Services – see

Reconstructive Services

Travel Expenses

Benefit Limit:

Network only

$50 per person daily limit per person, up to $100 total.

$10,000 Lifetime Maximum for organ transplant and cancer services

combined.

Non-Network – 0%

Includes transportation, meals purchased in the Hospital or Alternate

Facility and lodging for Patient not covered by Medicare and one

companion (two if Patient Member is minor child) for only cancer and

organ transplant Services.


Services for cancer and organ transplant must be received at a

COE;

facility must be more than 100 miles (most direct route) from

Patient’s permanent residence

Examples of

Covered Travel Expenses include airfare

at coach rate, taxi or ground

transportation and mileage reimbursement at the IRS rate for the most

direct route between Patient’s residence and Facility.


2013 Plan Year – Rev. 12/3/2012

transportation expenses are limited to travel of the Patient and

companion traveling on the same day(s) to and/or from the facility

for the purposes of an evaluation, the procedure or necessary post-

discharge follow-up; and

BCBS must receive valid receipts for such charges.

Vision Care – Generally Excluded

Covers only:

refractive eye care only if associated with a medical diagnosis such

as diabetes;

vision screenings part of an annual physical examination; and

the first pair of contact/glass lenses as treatment of keratoconus or

post cataract surgery and their fitting.

Excludes other vision care, such as routine eye exams and procedures

performed for the purpose of correcting refractive disorders (including

radial keratotomy), vision conditions such as nearsightedness

(myopia), farsightedness (hyperopia), astigmatism and the need for

reading glasses (presbyopia).

Well Child/Well Adult Care – see Preventive Services

Wigs

Benefit Limit: $500/calendar year Maximum combined for Network and

Non-Network

Covered only when there has been a temporary loss of hair resulting

from treatment of a malignancy or permanent loss of hair from an

accidental Injury.

Additional Excluded Services and Supplies

In addition to those Services and Supplies noted as Excluded or limited

in the previous section, the following Services or Supplies are Excluded

Health Care Services and Supplies under this Plan, even if they are

recommended or prescribed by a Provider or are the only available

treatment for your condition. This means that no Plan Benefits are

payable for expenses for the following general exclusions(unless they

are specifically included in the prior section (e.g., wigs)):

Alternative Treatments - acupressure, aromatherapy, hypnotism,

massage therapy, rolfing (holistic tissue massage) and art, music,

dance and horseback therapy and other forms of alternative

treatment as defined by the National Center for Complementary and

Alternative Medicine of the National Institutes of Health.

Autopsies and other coroner services and transportation services for

a corpse.

Chelation therapy, except to treat heavy metal poisoning.

Cosmetic Services and Supplies.


2013 Plan Year – Rev. 12/3/2012

Custodial Services not intended primarily to treat a specific Medical

Condition, or any education or training or Custodial Services

provided by a personal care assistant or care in a nursing or

convalescent home.

Diagnostic tests that are administered in other than a Doctor's

office, Hospital or Alternate Facility and self-administered home

diagnostic tests, including but not limited to HIV and pregnancy

tests.

Domiciliary Care, meaning living arrangements designed to meet the

needs of people who cannot live independently but do not require

Skilled Nursing Facility services.

Education therapy.

Experimental or Investigational Services and Supplies except for a

Prescription Drug on an Outpatient basis if the Claims Administrator

determines that:

the Medical Condition can be expected to cause death within

one year of the request for, in the absence of, the

Service/Supply; and

the Service or Supply, although unproven, has significant

potential as an effective treatment for the Medical Condition.

Services and Supplies received (1) for treatment of military service-

related disabilities other coverage for which the Patient is legally

entitled to at facilities that are reasonably available, whether or not

payment or benefits are received; (2) for Services for which

coverage is available while on active duty in the armed forces; (3)

for a Medical Condition resulting from (a) war or any act of war,

whether declared or undeclared, while the Patient is part of any

armed service force of any country or (b) or in the course of, any

employment for wage or profit, whether or not it is covered by

Workers’ Compensation or similar insurance.

Food, except meals that are covered Travel Expenses.

Growth hormone therapy.

Health club memberships and programs, and spa treatments.

Health education classes.

Health Services or Supplies provided or Prescription Drugs dispensed

outside of the United States unless required for an Emergency.

Income taxes.

Immunizations for travel or work.

Medical and appliance or surgical treatment of snoring, except when

provided as a part of treatment for documented obstructive sleep

apnea (a sleep disorder in which a person regularly stops breathing

for 10 seconds or longer) .

Personal Care, comfort or convenience items, including but not

limited to: television, telephone, beauty/barber service, guest


2013 Plan Year – Rev. 12/3/2012

service, air conditioners, purifiers and filters, batteries and chargers,

dehumidifiers and humidifiers, ergonomically correct chairs, non-

Hospital beds, comfort beds, motorized beds and mattresses, car

seats.

Physical, psychiatric or psychological exams, testing, vaccinations,

immunizations or treatments: when required solely for purposes of

career, education, sports or camp, employment, insurance, marriage

or adoption; as a result of incarceration; conducted for purposes of

medical research; related to judicial or administrative proceedings or

orders; or required to obtain or maintain a license of any type.

Respite care not associated with Hospice Care.

Rest cures.

Services performed at a diagnostic facility from a Provider affiliated

with the facility that is not actively involved in your Medical care

related to the Service.

Services or Supplies for sexual dysfunction including but not limited

to erectile dysfunction.

Spinal treatment to treat a condition unrelated to alignment of the

vertebral column, such as asthma or allergies.

Storage of blood, umbilical cord or other material for use in a

Covered Health Service, except if needed for an imminent surgery.

Therapy to improve general physical condition in the absence of a

diagnosis or not Restorative in nature.

Third party requests including reports, evaluations, examinations, or

hospitalizations not required for health reasons, such as:

employment, insurance or government licenses and court ordered

forensic or custodial evaluations.

Transportation, except as a covered Travel Expense.

Vocational rehabilitation or work hardening (individualized treatment

programs designed to return a person to work or prepare a person

for specific work.

Filing Claims

The following paragraphs explain when and how to file claims to your

Plan for Covered Health Expenses.

Network Benefits

In general, if you receive Covered Health Services or Supplies from a

Network Provider, including a Pharmacy, the Claims Administrator will

pay the Provider directly. Keep in mind, you are responsible for paying

any co-pay for Emergency Room at the time of the visit or for Out-of-

Pocket Expenses not paid by your HRA at the time of Service or when

you receive a bill from the Provider. If a Network Provider bills you for

any Covered Health Service or Supply other than for the amount of


2013 Plan Year – Rev. 12/3/2012

your Deductible or Co-insurance, please contact the Provider or call

the Claims Administrator at the phone number on your Medical or Rx

Member ID Card.

Non-Network Benefits

If you receive a bill for Covered Health Services or Supplies from a

Non-Network Provider, you (or the Provider) must send the bill to the

Claims Administrator for processing.

How to File a Claim

Obtain a medical coverage claim form from EHL (ehlticket or 800-697-

6000) or from the Claims Administrator at the address, or number or

website on the back of your Member ID card.

Read and follow the instructions on the claim form and mail your

completed form along with any supporting documentation or itemized

bills to the Claims Administrator. Include the group number for filing

claims under the Plan. Be sure to keep copies of your claims for future

reference.

Claim Filing Deadline

Claims for Covered Health Services or Supplies must be filed with the

applicable Claims Administrator no later than two years following the

date of the Service or Supply (one year following Prescription Drug

dispense) in order to be considered for reimbursement. Claims

submitted after the deadline will not be paid.

Payment of Benefits

After your claim has been processed, any Benefits will be paid to you

unless:

the Provider notifies the Claims Administrator that you have

provided signed authorization to assign Benefits directly to that

Provider; or

you make written requires for the non-Network Provider to be paid

directly at the time you submit your claim.

The Claims Administrator will not pay to a third party, even if your

Provider has assigned Benefits to that third party.

Mail Claim Form and Supporting

Documentation to…

MEDICAL

(BCBS)

PRESCRIPTION DRUG

(CVS Caremark)

Blue Cross Blue Shield of Illinois

P. O. Box 805107

Chicago, Illinois 60680-4112

CVS Caremark

P.O. Box 52136

Phoenix, Arizona

85072-2136


2013 Plan Year – Rev. 12/3/2012

It is your responsibility to pay the Provider the charges you incurred,

including any difference between what you were billed and what the

Plan paid.

Explanation of Benefits (EOB)

You may request that the Claims Administrator send you a paper copy

of an Explanation of Benefits (EOB) after processing the claim. The

EOB will let you know if there is any portion of the claim you need to

pay. If any claims are denied in whole or in part, the EOB will include

the reason for the denial or partial payment. If you would like paper

copies of the EOBs, you may call the toll-free number on your Member

ID card to request them. You can also view and print all of your EOBs

online at the applicable Claims Administrator’s website.

Voluntary Resources – Making the Most of Sprint Benefits

BCBS Case Management

Case Management is a voluntary service offered by the Plan to assist

you and your family in the event of a Member’s catastrophic Illness or

Injury — such as major head trauma, neonatal high-risk infants and

multiple sclerosis. A BCBS case manager works with you and the

Patient’s Attending Doctor to design and coordinate a treatment plan

that is comprehensive, practical and medically appropriate.

If you suffer such a major personal injury or develop a major illness,

the Plan may pay benefits for Services and Supplies that exceed the

Benefits that would be payable for such charges otherwise. For

example, if your case manager recommends a Skilled Nursing Facility

as an appropriate alternative for hospitalization, the Skilled Nursing

Facility day Maximum may be waived.

To determine the amount payable, the following is considered:

the Patient’s medical status,

the Patient’s current treatment plan,

the Patient’s projected treatment plan,

the long-term cost implications, and

the effectiveness of care.

Outside of these hours, you may leave a message and a representative

will return your call. This is a voluntary service.

Call Sprint

Alive!...

866-90-ALIVE

(25483)

0r *545 on your Sprint phone

24 hours a day…7

days a week

TTY/TDD Services

800-255-0135

(Relay Service) 800-229-5746

(Speech to Text Service)

or visit

www.sprintrelayonline.com

For Case Management Call…

877-284-1571

8 a.m. - 8 p.m.

(caller’s local time)

Monday - Friday

http://www.sprintrelayonline.com/



2013 Plan Year – Rev. 12/3/2012

Sprint Alive! Programs

Separate from this Plan, the following voluntary Sprint Alive! Programs

are available with no out-of-pocket costs or any impact to your Plan

benefits. Privacy guidelines are strictly followed. At no time

will your personal information be shared with Sprint.

Sprint Alive! Complex Case Management Program

BCBS may at times work with the Sprint Alive! Complex Case

Management program to help Sprint employees and their families with

high risk health care needs or when a medical condition creates

complicated health care needs. A specialty trained Registered Nurse

will work with you, your family, your doctor and other Providers to:

understand your health care needs;

identify potential gaps in your care;

set goals and develop a plan to help you manage your Medical

Condition;

provide educational information about your Medical Condition or

diagnosis;

help you understand your Doctor’s treatment plan;

provide information about your medications;

provide information to help you to prevent complications; and

determine if case management services are appropriate for your

needs.

Sprint Alive! Condition Assistance Program

The Sprint Alive! Condition Assistance Program is a benefit that helps

you take an active role in manage certain health conditions effectively.

This valuable program is like having a personal support team —

Registered Nurses, health educators and dieticians — all available to

answer confusing medical questions, educate you on a condition or

diagnosis, or help you better understand your Doctor’s course of

treatment.

The Program is available for the following conditions:

Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Heart Conditions:

o Coronary Artery Disease (CAD)

o Congestive Heart Failure (CHF)

Diabetes*

Low Back Pain

Cancer Support

Emotional Health

Employees and

Spouses/ Domestic

Partners enrolled in the Sprint Alive! Diabetes Management Program and

completing specific criteria receive a supplemental credit of $400 added to their HRA. (up to

$800 in credit).

**The Sprint Alive Maternity Program offers a toll-free baby hotline,

maternity case management and an electronic OB newsletter and library.


2013 Plan Year – Rev. 12/3/2012

Maternity**

Kidney

Sprint Alive! 24-Hour Nurse Advocate/Health Information

Whether you need information about how to care for a crying baby,

how to treat a skin rash, want help planning a diet or have an urgent

or emergency situation, help is just a phone call away! Sprint Alive! is

an additional resource for you in the event you cannot speak with your

Doctor providing:

a team of RNs who are on duty around the clock, seven days a

week, to assess the symptoms you describe and make recommendations on the appropriate method of care; and

access to the Health Information Audio Library, which provides pre-

recorded general information on hundreds of health and medical

topics.

Helpful Numbers and Information

BCBS

877-284-1571

For This Service... Call During These Hours...

Personal Health Support 8 a.m. - 6 p.m. (caller’s local time)

Monday – Friday

Pre-Authorization/Case

Management

8 a.m. - 6 p.m. (Central time)

Monday – Friday

Internet

www.bcbsil.com/sprint (pre-member) www.bcbsil.com (member)

My Life & Career>Benefits>Benefits Overview

CVS Caremark

855-848-9165

www.caremark.com/sprint (pre-member)

www.caremark.com (member)

My Life & Career>Benefits>Benefits Overview

Sprint Alive!

24-Hour Nurse Advocate/Health Information and Condition Assistance Program

866-90-ALIVE (25483) or www.sprintalive.com

Anytime

TTY/TDD Services

800-255-0135 (Relay Service)

800-229-5746 (Speech to Text

Service)

or

www.sprintrelayonline.com

Employee Help Line (EHL)

http://www.welcometouhc.com/sprinthealth


http://www.caremark.com/sprint


http://www.sprintalive.com/



2013 Plan Year – Rev. 12/3/2012

When Coverage Ends

For information on when your coverage under the Plan ends, see the

separate Eligibility & Enrollment and Life Events Sections of the SPD

incorporated herein by reference on the Benefits site of i-Connect

under Summary Plan Descriptions.

Extended Benefits

If you or one of your Covered Dependents is Totally Disabled on the

date his/her coverage under this Plan ends, Plan Benefits are payable

with respect to the condition that caused the Total Disability as if the

coverage had not ended. These “Extended Benefits” will be based on

the terms of the Plan in effect on the date the coverage ended.

Extended Benefits are payable until the earliest of the:

date the person is no longer Totally Disabled by the condition that

caused Total Disability;

end of the calendar year following the calendar year in which the

coverage ended;

date the person becomes eligible for benefits that are similar under

any other group arrangement, whether insured or self-insured; or

date the Plan ends or the date coverage ends for the class of

Members of which the person is a member.

Totally Disabled/Total Disability means, if, due to an accidental Injury

or Illness:

in the case of a Sprint employee, the person is unable to do any

work for compensation or gain; and

in the case of a Member who is not a Sprint employee, the person

is unable to do all the normal tasks for that person’s age and

family status.

Other Important Information

Coordination of Benefits

When You Are Covered by More than One Plan

Today, many people are covered by more than one group medical

plan. If this applies to you (or your Covered Dependents), you must

let the Claims Administrator know about the other coverage.

This Plan, like most group plans, has a coordination of benefits

provision for these situations. The provision coordinates benefits from

all group medical plans — including benefits paid under a prepayment,

i-Connect

ehlticket

Or 800-697-6000

This Plan coordinates benefits with

other group coverage you may have.


2013 Plan Year – Rev. 12/3/2012

employer sponsored or government program, including Medicare —

covering you and your Covered Dependents. That is, this Plan and

other group medical plans work together to pay covered health

expenses. This Plan’s COB provision does this by determining which

plan is primary (see below).

Coverage, however, is non-duplicative. So, if you have coverage

under more than one group medical plan, including this one,

this Plan, together with payments from other plans, will never

pay more than what you would have received if this were your

only plan.

If this Plan is primary, Benefits will be paid as if no other plan

exists.

If this Plan is the secondary payer, Benefits from this Plan will be

paid to the extent that, when benefits from both plans are added

together, the total is not more than what this Plan would have paid

if no other plan exists. To do this, Benefits will be calculated under

this Plan as if it were primary. Then, this Plan will subtract what

was paid by the other plan and pay the remaining amount (if any)

— up to the total that would have been paid under this Plan alone.

When this Plan is secondary, the Allowable Expense is the primary

plan's Network rate or reasonable and customary charges. If both

the primary plan and this Plan do not have a contracted rate, the

Allowable Expense will be the greater of the two plans' reasonable

and customary charges. An Allowable Expense is a health care

expense that is covered at least in part by one of the health benefit

plans covering you.

When you incur Covered Health Expenses, you must submit a claim to

the primary plan before the secondary plan. Once you receive

benefits from the primary plan, you can submit a claim to the

secondary plan. You must include a copy of payment or the

Explanation of Benefits from the primary plan.

Which Plan Is Primary?

Except as explained in the Medicare and this Plan Section below, the

Claims Administrator is responsible for determining which plan is

considered primary — and, therefore, which pays benefits first. As a

rule, if a Covered Dependent child is the Patient, the plan covering the

parent whose birthday comes earlier in the calendar year will pay first.

If there is a court decree that establishes financial responsibility for

medical care of the child, the benefits of the plan that covers the child

as a dependent of the parent so responsible will be determined before

any other plan; otherwise:

The benefits of a plan that covers the child as a dependent of the

parent with custody will be determined before a plan that covers

the child as a dependent of a stepparent or a parent without

custody.

Once you become eligible

for Medicare, coordination of benefits may change — see the Medicare and this Plan

section below.


2013 Plan Year – Rev. 12/3/2012

The benefits of a plan that covers the child as a dependent of a

stepparent will be determined before a plan that covers the child as a dependent of the parent without custody.

Medicare and this Plan

A Note about Medicare

Medicare coverage is extended to persons turning age 65 or in various

circumstances of entitlement to or eligibility for Social Security

Disability or Railroad Retirement Board Benefits, including Lou Gehrig’s

Disease, and End Stage Renal Disease.

There are three parts to Medicare coverage relevant to your coverage

under the Plan:

Medicare Part A hospital insurance coverage is generally automatic

and at no cost to you.

Medicare Part B medical insurance coverage is always optional,

meaning, you must sign up for it, and there is always a cost to you

for Part B.

Medicare Part D prescription drug coverage is also optional, and

you must sign up and pay for it as well.

There are specified enrollment periods for optional Medicare coverage,

and there is a premium penalty for failing to enroll within the

applicable period.

Since there is a monthly premium for optional Medicare coverage,

however, and many of the expenses under that optional Medicare

coverage are covered by this Plan, you may wonder whether you

should enroll in Medicare coverage. The answer to that depends on the

Medicare rules and this Plan as described below.

Impact of Medicare Eligibility or Entitlement

Medicare rules generally require this Plan to remain primary even

when Medicare Part A becomes effective, except as provided below.

This means:

When this Plan is primary to Medicare for a person, then, just as

described in the Coordination of Benefits Section above, Plan

Benefits will be paid for that person’s Eligible Health Care Expenses

as if no other plan exists. If any bills remain unpaid after the Plan

has paid to the limits of its coverage, then you would file a claim

with Medicare.

Your penalty-free enrollment period for optional Medicare coverage

will be extended until after your coverage under this Plan ends, or,

if earlier after 30 months of Medicare coverage due to ESRD.

The first exception is that the Medicare rules do not require this Plan to

remain primary for domestic partners and their children. At Sprint’s

election, however, this Plan will remain primary for any domestic

partners or their children not covered by Medicare Part B or C.

For questions

about Medicare, call Social Security’s toll-free number (800) 772-1213,

any business day

from 7:00 a.m. to 7:00 p.m. or your local Social Security office.

It is important to enroll in Medicare coverage when you are first

eligible if you are, or your coverage under this Plan is through a Member who is, no longer a Sprint employee.


2013 Plan Year – Rev. 12/3/2012

This Plan’s remaining primary does not delay the penalty-free

enrollment period for those persons, so domestic partners and their

children are encouraged to enroll in optional Medicare coverage during

their enrollment periods.

The second exception is that when your coverage under this Plan

continues after the Sprint employee’s termination of employment

(e.g., during any period of COBRA continuation or the employee’s

receiving Sprint Long-Term Disability Benefits):

This Plan will become secondary for any Member becoming

Medicare-eligible, and, just as described in the Coordination of

Benefits section above, Benefits under this Plan will be reduced by

the benefits paid by Medicare, the primary plan.

o Benefits from this Plan will be paid to the extent that, when

benefits from both this Plan and Medicare are added together,

the total is not more than what this Plan would have paid if no

other plan exists.

o Claims must first be filed with Medicare and then with this Plan.

When you receive an Explanation of Medicare Benefits form,

submit it to the Claims Administrator along with your Plan claim

form.

This Plan assumes the Medicare-eligible Member has Part A and

Part B Medicare and any benefits payable from this Plan for that

person will be reduced by the amount that is or would be covered

by each part, whether or not he or she is enrolled in

Medicare; and

This Plan will no longer consider Prescription Drugs as a

Covered Health Care Supply for the Medicare-eligible

Person, whether or not he or she is enrolled in Part D. This

Plan will issue a Notice of Creditable Coverage to the applicable

person.

The Plan’s Rights

The Plan has rights that are described in detail in the Sprint Nextel

Welfare Benefits Plan for Employees, of which the Plan is a part. A

copy of the Welfare Benefits Plan for Employees can be obtained by

contacting the EHL (ehlticket or 800-697-6000). Any Benefits paid by

the Plan are deemed made on the condition of these rights, some of

which are:

subrogation rights, which means that if a Member receives benefits

under the Plan and has a claim for recovery against another party,

that claim will belong to the Plan up to the amount of Benefits paid.

The Member is required to assist the Plan in enforcing its

subrogated claim.

the right to recover Benefits that were made in error, advanced

during the period of meeting the Deductible or Out-of-Pocket Limit,

due to a mistake in fact, or because a Member misrepresented

facts. If the Plan provides a Benefit that exceeds the amount that

should have been paid, the Plan will require that the overpayment

Once this Plan becomes

secondary to Medicare for you, you may wish to end your coverage. If you do, and you are

a former Sprint employee, any of your Covered Dependents will remain covered under this Plan in their own

right.


2013 Plan Year – Rev. 12/3/2012

be returned when requested, or reduce a future Benefit payment

for the applicable Member by the amount of the overpayment.

a right to reimbursement, which means that if a third party causes

an Illness or Injury for which you receive a settlement, judgment,

or other recovery, you must use those proceeds to fully return to

the Plan 100% of any Benefits you received for that Illness or

Injury.

Legal Information

For other important information about the Plan Sponsor and

Administrator, Sprint employers participating in the Plan, Plan

identification, agent for service of legal process, ERISA rights,

including claims and appeals procedures, and other legally required

notices regarding the Plan, see the separate Legal Information Section

of the SPD incorporated herein by reference on the Benefits site of i-

Connect under Summary Plan Descriptions.

Definitions

Allowable Amounts means the following:

1. For Covered Health Services and Supplies from a Network Provider,

the contracted rates with the Provider;

2. For Covered Health Services and Supplies from a Non-Network

Provider for a Member’s Emergency, the amounts billed by the

Provider, unless the Claims Administrator negotiates lower rates;

and

3. For other Covered Prescription Drugs, the comparable network

Provider rate, and for other Covered Medical Health Services and

Supplies from a Non-Network Provider, one of the following, as

applicable:

negotiated rates agreed to by the Non-Network Provider and

either the Claims Administrator or one of its vendors, affiliates or

subcontractors, at the discretion of the Claims Administrator;

200 (100 with respect to Providers in Illinois) percent of the

published rates allowed by the Centers for Medicare and Medicaid

Services (CMS) for Medicare for the same or similar Service or

Supply within the geographic market;

When a rate is not published by CMS for the Medical Service or

Supply, the Claims Administrator uses an available gap

methodology to determine a rate for the Medical Service or

Supply as follows –

For Service or Supply other than Doctor-administered

Pharmaceutical Products, BCBS uses a gap methodology that

uses a relative value scale, which is usually based on the

difficulty, time, work, risk and resources of the Service or

Supply. The relative value scale currently used is created by

Ingenix. If the Ingenix relative value scale becomes no longer

available, a comparable scale will be used. BCBS and Ingenix

are related companies through common ownership by BCBS.

For Doctor-administered Pharmaceutical Products, BCBS uses

gap methodologies that are similar to the pricing

methodology used by CMS, and produces fees based on

This section

defines terms that are used throughout this Section of the SPD.


2013 Plan Year – Rev. 12/3/2012

published acquisition costs or average wholesale price for the

pharmaceuticals; or

When a rate is not published by CMS for the Service and a gap

methodology does not apply to the Medical Service, or the

Provider does not submit sufficient information on the claim to

pay it under CMS published rates or a gap methodology, 50% of

the Provider’s billed charge (80% of the Provider’s billed charge

for Mental Health/Substance Use Disorder Services, reduced by

25% for Services provided by a psychologist and by 35% for

Services provided by a masters level counselor).

Allowable Amounts are subject to the Claims Administrator’s

reimbursement policy guidelines, which are applied in its discretion, a

copy of which related to your claim is available upon request to the

Claims Administrator.

Alternate Facility means a health care facility that is not a Hospital

that, as permitted by law, provides Emergency, surgical, rehabilitative,

laboratory, diagnostic, therapeutic on an outpatient basis, or with

respect to Mental Health/Substance Use Disorder Services on an

outpatient or inpatient basis, including an Urgent Care Center, Birthing

Center, Skilled Nursing Facility or Rehabilitation Facility.

Attending Doctor means a Doctor who is in charge of the Patient’s

overall medical care and responsible for directing his or her treatment

program.

Benefits means the Plan payments for Covered Health Expenses,

subject to the terms and conditions of the Plan. Benefits are your HRA

and Benefit Levels.

Benefit Levels means the percentage of Covered Health Expenses

payable by the Plan during and after the Coinsurance phase of

coverage.

Brand-name Drug means a Prescription Drug that is either:

manufactured and marketed under a trademark or name by a

specific drug manufacturer; or

identified by CVS Caremark as a Brand-name Drug based on

available data resources including, but not limited to, First

DataBank, that classify drugs as either Brand-name or Generic

Drugs based on a number of factors.

Not all products identified as “brand name” by the manufacturer,

Pharmacy, or your Doctor are classified as Brand-name by CVS

Caremark.

Claims Administrator – see page 1.

COE means a Center of Excellence, which is a clinically superior, cost-

effective health care center for complex medical conditions, as

identified by BCBS.

Coinsurance – see page 3.

Coordination of Benefits means a provision that coordinates benefits

from all group medical plans.


2013 Plan Year – Rev. 12/3/2012

Compounded means those medications containing two or more

ingredients that are combined "on-site" by a pharmacist, provided at

least one of the ingredients is covered by the Plan.

Congenital Anomaly means an abnormality or malformation of the

structure of a body part, such as curvature of the 5th finger

(clinodactyly), a third nipple, tiny indentations of the skin near the

ears (preauricular pits), shortness of the 4th metacarpal or metatarsal

bones, or dimples over the lower spine (sacral dimples).

Co-pay – see page 5.

Cosmetic means primarily for appearance purposes, as opposed to

physiological function, for example: reshaping a nose with a prominent

bump because appearance would be improved, but there would be no

improvement in function like breathing; liposuction; pharmacological

regimens; nutritional procedures or treatments; tattoo or scar removal

or revision procedures (such as salabrasion, chemosurgery and other

such skin abrasion procedures); replacement of an existing intact

breast implant if the earlier breast implant was performed as a

Cosmetic Procedure; physical conditioning programs such as athletic

training, bodybuilding, exercise, fitness, flexibility, and diversion or

general motivation; weight loss programs whether or not they are

under medical supervision or for medical reasons, even if for morbid

obesity; treatments for hair loss or replacement; a procedure or

surgery to remove fatty tissue such as panniculectomy,

abdominoplasty, thighplasty, brachioplasty, or mastopexy; varicose

vein treatment of the lower extremities; wigs except as covered under

Wigs; and treatment of benign gynecomastia (abnormal breast

enlargement in males).

Covered Dependent means a Sprint employee’s spouse/domestic

partner or dependent child who is properly enrolled in this Plan

pursuant to the Eligibility and Enrollment Section of the SPD

incorporated herein by reference on the Benefits site of i-Connect

under Summary Plan Descriptions.

Covered Health Expense – see page 7.

Covered Health Service or Supply – see page 8.

Custodial Care means a Service that does not require special skills or

training or is provided by a Personal Care attendant and that:

provides assistance in activities of daily living (including but not

limited to feeding, dressing, bathing, ostomy care, incontinence

care, checking of routine vital signs, transferring and ambulating);

is provided for the primary purpose of meeting the personal needs

of the patient or maintaining a level of function (even if the specific

services are considered to be skilled services), as opposed to

improving that function to an extent that might allow for a more

independent existence; or

does not require continued administration by trained medical

personnel in order to be delivered safely and effectively.

DAW means “Dispense as Written;” i.e., your Provider’s instruction to

not allow substitution of a Therapeutically Equivalent Prescription Drug

for the prescribed Brand-name Prescription Drug.

Deductible – see page 2.

http://en.wikipedia.org/wiki/Clinodactyly


2013 Plan Year – Rev. 12/3/2012

Dental means of or related to diagnosis (e.g., oral evaluations,

examinations, x-rays/films, lab tests, casts), prevention (e.g., dental

prophylaxis (dental cleanings), topical fluoride treatments, nutritional

counseling for dental disease, tobacco counseling for oral disease, oral

hygiene instructions, sealants, space maintainers) or treatment (see

below) of diseases, disorders and conditions of the oral cavity, the

maxillofacial area and the adjacent and associated structures. Dental

treatment includes Services and Prescription Drugs and other Supplies

that are (a) restorative (e.g., amalgam restorations (silver fillings),

resin restorations (white fillings), gold foil restorations, inlay/onlay

restorations, crowns, core buildups, posts); (b) endodontic (e.g., pulp

capping, pulpotomy, pulpal therapy, root canals, apicoectomy); (c)

periodontic (e.g., gingivectomy, gingivoplasty, crown lengthening,

osseous surgery, grafting procedures, provisional splinting, scaling and

root planing, full mouth debridement, periodontal maintenance); (d)

prosthodontic (removable or fixed) (e.g., complete dentures, partial

dentures, interim dentures, denture repairs, denture rebase, denture

reline, denture pontics, denture inlays/onlays, denture crowns, dental

implants, retainers); (e) surgical (e.g., extractions, excisions,

alveoloplasty (surgical preparation for dentures), vestibuloplasty

(surgery to increase alveolar ridge height); (f) orthodontic (e.g.,

appliance therapy, orthodontic braces, retainers); and (g) adjunctive

(e.g., anesthesia, occlusal guards (bite plates/guards), athletic

mouthguards, occlusal adjustments to teeth, teeth bleaching).

Dentist means a Doctor of Dental Surgery (DDS) or Doctor of Dental

Medicine (DMD) licensed in the jurisdiction of practice with respect to

the Patient.

Disposable means of or related to short term or single usage, whether

or not consumable.

Doctor means a Doctor of Medicine (MD) or Doctor of Osteopathic

Medicine (DO) licensed in the jurisdiction of practice with respect to

the Patient.

Durable Medical Equipment (DME) means items that are designed for

and able to withstand repeated use by more than one person;

customarily serve a medical purpose; generally are not useful in the

absence of Injury or Illness; are appropriate for use in the home; and

are not Disposable.

Examples of DME include but are not limited to:

equipment to assist mobility, such as wheelchairs;

respirators;

dialysis machines;

equipment to administer oxygen;

Hospital beds;

delivery pumps for tube feedings;

insulin pumps;

negative pressure wound therapy pumps (wound vacuums);

burn garments

braces that straighten or change the shape of a body part;

braces that stabilize an injured body part, including necessary

adjustments to shoes to accommodate braces;

equipment for the treatment of chronic or acute respiratory failure

or conditions; and

http://en.wikipedia.org/wiki/Diseases

http://en.wikipedia.org/wiki/Mouth


2013 Plan Year – Rev. 12/3/2012

speech aid devices and trachea-esophageal voice devices for

treatment of severe speech impediment or lack of speech directly

attributed to Sickness or Injury.

DME excludes hygienics or self-help items; environmental controls,

institutional, or convenience equipment; equipment used for

participation or safety in sports or recreational activities; blood

pressure cuff/monitor, enuresis alarm, non-wearable external

defibrillator, trusses, ultrasonic nebulizers; devices and computers to

assist in communication and speech except for speech aid and

tracheo-esophageal voice devices; and fixtures to real property such

as ramps, railings and grab bars.

Emergency means a Medical Condition that arises suddenly and in the

judgment of a reasonable person requires immediate are and

treatment, generally received within 24 hours of onset, to avoid

jeopardy to life or health.

Experimental or Investigational means at the time of receipt of Service

or Supply (other than Prescription Drugs during an Inpatient Stay) any

of the following: not approved by the U.S. Food and Drug

Administration (FDA) to be lawfully marketed for the proposed use and

not identified in the American Hospital Formulary Service or the United

States Pharmacopoeia Dispensing Information as appropriate for the

proposed use; subject to review and approval by any institutional

review board for the proposed use, except devices that are FDA-

approved under the Humanitarian Use Devise exemption; or the

subject of an ongoing Clinical Trial that meets the definition of a Phase

1, 2 or 3 Clinical Trial set forth in the FDA regulations, regardless of

whether the trial is actually subject to FDA oversight.

Explanation of Benefits means a statement describing payment

processing of your claim. If any claims are denied in whole or in part,

the EOB will include the reason for the denial or partial payment and

show the portion of the claim you need to pay. If you would like paper

copies of the EOBs under this Plan, you may call the toll-free number

on your Member ID card to request them. You can also view and print

all of your EOBs online at the applicable Claims Administrator’s

website.

Generic Drug means a Prescription Drug that is not a Brand-name drug

and either:

contains the same active ingredient as a Brand-name Drug; or

is identified by CVS Caremark as a Generic Drug based on available

data resources including, but not limited to, First DataBank, that

classify drugs as either Brand-name or Generic Drugs based on a

number of factors.

All products identified as a “generic” by the manufacturer, Pharmacy

or your Doctor may not be classified as a Generic by CVS Caremark.

Home Health Agency means a program or organization authorized by

applicable law to provide health care services in the home.

Hospice Care means a Service that provides a coordinated plan of

home and inpatient care that treats a terminally ill patient and his or

her family as a unit. The service provides care to meet the special


2013 Plan Year – Rev. 12/3/2012

needs of the family unit during the final stages of a terminal illness

and during bereavement up to 12 months after the Member’s death. A

team of trained medical personnel, homemakers and counselors work

under a BCBS-approved independent hospice administration,

approved by all state or local licensing requirements, to provide care

and to help the family unit cope with physical, psychological, spiritual,

social and economic stress.

Home Health Care means an alternative health care Service that a

Home Health Agency provides that mainly provides Skilled Care, is

legally qualified in the state or the locality in which it operates, and

keeps clinical records on all patients. The term does not include

Services of a social worker or home health aide or Services of a

homemaker or caretaker, including but not limited to sitter or

companion services, transportation, house cleaning, and maintenance

of the home, or other Custodial Care.

Hospital means a legally constituted and operated institution that is

primarily engaged in providing inpatient diagnostic and therapeutic

facilities for the surgical and medical diagnosis, treatment and care of

sick persons under the supervision of staff doctors who are duly

licensed to practice medicine, and which provides nursing service 24

hours a day by registered graduate nurses — physically present and

on duty. A Hospital is not an institution (or part of an institution) that

is mainly used for rest care, nursing care, convalescent care, elder

care, care of the chronically ill, Custodial Care or educational care.

Illness means physical illness, disease or pregnancy.

Injury means bodily damage from trauma other than Illness, including

all related conditions and recurrent symptoms. Inpatient Rehabilitation Facility means a Hospital (or a special unit of a

Hospital that is designated as an Inpatient Rehabilitation Facility) that

provides physical therapy, occupational therapy and/or speech therapy

on an inpatient basis, as authorized by applicable law.

Inpatient Stay means an uninterrupted confinement in, following

formal admission to, a Hospital, Skilled Nursing Facility, or

Rehabilitation Facility.

Intensive Outpatient Treatment means a structured outpatient Mental

Health or Substance Use Disorder treatment program that may be

free-standing or Hospital-based and provides services for at least three

hours per day, two or more days per week.

Life Event – see Life Events Section of the SPD herein by reference on

the Benefits site of i-Connect under Summary Plan Descriptions.

Medical means of or related to diagnosing, treating or preventing

Medical Conditions.

Medical Condition means Illness, including Mental Health or Substance

Use Disorders, or Injury, and its symptoms.

Medically Necessary/Medical Necessity means for the purpose of

preventing, evaluating, diagnosing or treating a Medical Condition and:


2013 Plan Year – Rev. 12/3/2012

in accordance with Generally Accepted Standards of Medical

Practice;

clinically appropriate (in terms of type, frequency, extent, site and

duration) and effective for your Medical Condition;

not mainly for your convenience or that of your Doctor or other

Provider; and

not more costly than an alternative Service or Supply that is at

least as likely to produce equivalent therapeutic or diagnostic

results, as specified in the Claims Administrator’s clinical policies.

Generally Accepted Standards of Medical Practice are standards

that are based on (a) credible scientific evidence published in peer-

reviewed medical literature generally recognized by the relevant

medical community, relying primarily on controlled clinical trials or,

if not available, observational studies from more than one

institution that suggest a causal relationship between the service or

treatment and health outcomes; or if not available (b) standards

based on Doctor specialty society recommendations or professional

standards of care.

Medicare means Parts A, B, C and D of the insurance program

established by Title XVIII, United States Social Security Act, as

amended by 42 U.S.C. Sections 1394, et seq. and as later amended.

Member means a person properly enrolled for coverage under this Plan

pursuant to the rules described in the Enrollment & Eligibility Section

of the SPD incorporated herein by reference on the Benefits site of i-

Connect under Summary Plan Descriptions.

Network means the network of Providers under this Plan selected by

the Claims Administrator within which amounts charged the Provider

are negotiated, contracted rates and are automatically considered

Allowable Amounts.

Network Provider means a health care Provider who has entered into

an agreement with the Claims Administrator or an affiliate and agreed

to accept specified reimbursement rates for Covered Health Services

and Supplies.

Non-Emergency means Services or Supplies that are provided to a

Member in a situation that does not meet the criteria for being an

Emergency.

Non-Network means Services or Supplies provided outside of the

Plan’s Network.

Non-preferred Brand-name Drug means a Brand-name Drug that is not

identified by CVS Caremark as being on the Preferred Drug List (PDL).

Out-of-Pocket Limit – see page 5.

Partial Hospitalization/Day Treatment means a structured ambulatory

program that may be a free-standing or Hospital-based program and

that provides services for at least 20 hours per week.

Patient means a Member of this Plan who receives Medical Services or

Supplies.


2013 Plan Year – Rev. 12/3/2012

Pharmaceutical Products means certain injectable drugs allergy sera or

extracts that, due to their characteristics (as determined by BCBS),

must typically be administered or directly supervised by a Doctor but

not typically available by prescription order or refill at a Pharmacy.

Pharmacy means a retail or home delivery organization lawfully

dispensing Prescription Drugs.

Plan means The Sprint Consumer Access Medical Plan.

Plan Administrator means the Employee Benefits Committee of Sprint.

Plan Sponsor means Sprint Nextel Corporation (Sprint).

Preferred Brand-name Drug means a Brand-name Drug that is

identified by CVS Caremark as being on the Preferred Drug List (PDL).

Preferred Drug List (PDL) - a list that categorizes medications,

products or devices that have been approved by the U.S. Food and

Drug Administration. CVS Caremark's Pharmacy & Therapeutics

Committee makes the final approval of Prescription Drug placement in

tiers, taking into account a number of factors including, but not limited

to the following clinical and economic factors regarding Members as a

general population.

evaluations of the place in therapy;

relative safety and efficacy and whether Supply Limits apply;

the acquisition cost of the Prescription Drug; and

available rebates and assessments on the cost effectiveness of the

Prescription Drug.

The PDL organizes all Prescription Drugs into tiers:

Tier 1: Generic

Tier 2: Preferred Brand-name

Tier 3: Non-preferred Brand-name

Prescription Drug means a medication or other Supply (excluding

Durable Medical Equipment except as included below and excluding

Pharmaceutical Products other than Depo Provera and other injectable

drugs used for contraception) that contains at least one ingredient that

has been approved by the Food and Drug Administration, that can

under federal or state law be dispensed legally only pursuant to a

prescription order or refill (i.e., not over-the-counter drugs, except as

otherwise provided by CVS Caremark and obtained with a prescription

order or refill from a Doctor), is dispensed by a Pharmacy, and has

been assigned to the PDL, including a medication that, due to its

characteristics, is appropriate for self-administration or administration

by a non-Skilled Caregiver, including:

inhalers (with spacers);

insulin; and

the following diabetic supplies:

o insulin syringes with needles;

o blood testing strips - glucose;

o urine testing strips - glucose;

o ketone testing strips and tablets;

o lancets and lancet devices;

The PDL category

status of a Prescription Drug can change periodically without notice; visit

www.caremark.com

or call Caremark at the toll-free number on your Rx Member ID card for the most current

information.



2013 Plan Year – Rev. 12/3/2012

o insulin pump supplies, including infusion sets, reservoirs, glass

cartridges, and insertion sets; and

o glucose monitors.

Preventive Prescription Drugs means those certain Prescription Drugs

based on applicable federal regulatory guidance for this Plan.

Preventive Services means Services that have been demonstrated by

clinical evidence to be safe and effective in either the early detection

or the prevention of disease, have been proven to have a beneficial

effect on the health outcomes and include the following as required

under applicable law as follows:

1. immunizations that have a current recommendation from the

Advisory committee on Immunizations Practices of the Centers for

Disease Control and Prevention;

2. evidence-informed preventive care and screenings provided for in

the comprehensive guidelines supported by the Health Resources

and Services Administration; and

3. evidence-based Services that have in effect a rating of “A” or “B” in

the current recommendations of the United States Preventive

Services Task Force, limited to the sex, age and frequencies as

noted, except as Medically Necessary:

Abdominal Aortic Aneurysm Screening— A one-time

screening for men 65-75, Smokers

Alcohol Misuse Screening and Behavioral Counseling – Men,

women and pregnant women

Anemia Screening – Routine screening for iron deficiency

anemia in asymptomatic pregnant women

Aspirin to Prevent CVD: Men age 45 to 79 to prevent

myocardial infractions; Women age 55 to 79 to prevent

ischemic strokes

Asymptomatic Bacteriuria Screening -- pregnant women at

12-16 weeks’ gestation or at the first prenatal visit, if later

BRCA Mutation Testing for Breast and Ovarian Cancer --

Women, increased risk

Breast Cancer Preventive Medication Discussion – Women,

increased risk

Breast Cancer Screening with Mammography – With or

without clinical breast examination, every 1-2 years for

women age 40 years and older

Breastfeeding: Primary Care Interventions to Promote – All

pregnant women and new mothers

Cervical Cancer Screening -- women who are sexually active

Chlamydia Screening -- Pregnant women ages 24 and

younger OR pregnant women ages 25 and older at increased

risk; Women ages 24 and younger OR women ages 25 and

older at increased risk

Cholesterol abnormalities screening: Men aged 20-35,

increased risk; Men age 35 and older for lipid disorders;

Women age 20 and older, increased risk

Colorectal Cancer Screening -- Adults, beginning at age 50

years and continuing until age 75 years using fecal occult

blood testing, sigmoidoscopy, or colonoscopy

Congenital Hypothyroidism Screening -- Newborns

Dental Caries Oral Fluoride Supplementation – Preschool


2013 Plan Year – Rev. 12/3/2012

Children 6 Months and Older

Depression Screening -- Adolescents, 12-18 years of age, in

clinical practices with systems of care; Adults age 18 and

over -- when staff-assisted depression care supports are in

place

Diabetes Screening – For type 2 diabetes in asymptomatic

adults with sustained blood pressure (either treated or

untreated) greater than 135/80 mm Hg

Folic Acid Supplementation -- All women planning or capable

of pregnancy

Gonorrhea Screening -- Pregnant Women and Women at

increased risk

Gonorrhea Preventive Medication – Newborns

Healthy Diet Counseling -- Adults with Hyperlipidemia and

Other risk factors for CVD

Hearing Loss in Newborns Universal Screening -- Newborns

Hepatitis B Virus Screening -- Pregnant women

High Blood Pressure Screening -- Adults 18 and over

HIV Screening -- Adolescents and adults, increased risk

Iron Deficiency Anemia: Iron Supplementation –

Asymptomatic Children 6-12 months, increased risk

Iron Deficiency Anemia Screening -- Asymptomatic Pregnant

women

Lipid Disorders in Adults Screening -- Men 20-34, increased

risk for CHD; Women 20-44, increased risk for CHD; Men 35

and older; Women 45 and older, increased risk for CHD

Obesity Screening -- Children and Adolescents, Age 6-17

Obesity Screening and Intensive Counseling -- Obese men

and women

Osteoporosis Screening -- Postmenopausal women 65 years

and older with no risk factors, or 60 years and older with risk

factors

Phenylketonuria (PKU) Screening – Newborns

Physicals

Prostate Exam – Males 40 years and older

Rh(D) Blood Typing Screening -- Pregnant women (first

pregnancy related visit)

Rh(D) Blood Typing Screening -- Antibody Testing

Unsensitized Rh (D)-Negative pregnant women

Sexually Transmitted Infections Behavioral Counseling—

Sexually active adolescents and Adults at Increased Risk

Sickle Cell Disease Screening – Newborns

Syphilis Screening - Pregnant women; Men and women at

increased risk

Tobacco Use Counseling and Interventions – Adults;

Pregnant women

Visual Impairment Screening -- Children Younger than 5

years

Well woman exam (Breast/Pelvic Exam, Contraceptive

Information / Counseling, Minor Infection Treatment, Pap

Smear, Other Vaginal Smear, Rectal Exam, Urinalysis)


2013 Plan Year – Rev. 12/3/2012

Private Duty Nursing means nursing care that is provided to a Patient

for a period greater than four hours per day on a one-to-one basis by

licensed nurses.

Prosthetic Devices means items that replace a limb or body part, or

help an impaired limb or body part work, such as artificial limbs, legs,

feet, hands, eyes, ears, nose and face; breast prostheses, including

mastectomy bras and lymphedema stockings for the arm; and internal

prosthetic/medical appliances that provide permanent or temporary

internal functional supports for nonfunctional body parts.

Provider means a Pharmacy, Hospital, Alternate Facility, Doctor,

Dentist, or other licensed medical professional who is not at the time

the Service is rendered:

the Patient’s family member by birth or marriage, including his/her

spouse, brother, sister, parent or child

living at the same legal residence as the Patient;

a Christian Science practitioner; or

an unlicensed Provider or a Provider who is operating outside of the

scope of his/her license; or sanctioned under a federal program for fraud, abuse or medical

incompetency.

Service means a Medical examination, diagnosis, or treatment,

including prevention, Surgery, therapy and related care by a Provider.

Skilled Care means skilled nursing, teaching, and rehabilitation

Services that require clinical training in order to be delivered safely

and effectively, are delivered or supervised by licensed technical or

professional medical personnel in order to obtain the specified medical

outcome and provide for the safety of the Patient, and are not

Custodial Care.

Skilled Nursing Facility means a nursing facility that is licensed and

operated as required by applicable law, including that which may be

part of a Hospital.

Sprint means Sprint Nextel Corporation and, as applicable, any of its

subsidiaries participating in the Plan.

Supply means a Medical product, including a Pharmaceutical

Product, a Prescription Drug, a Disposable Medical Supply or

Durable Medical Equipment.

Surgery to Change Secondary Sex Characteristics means thyroid

chondroplasty (reduction of the Adam's Apple), bilateral

mastectomy, and augmentation mammoplasty (including breast

prosthesis if necessary) if the Doctor prescribing hormones and

the surgeon have documented that breast enlargement after

undergoing hormone treatment for 18 months is not sufficient for

comfort in the social role.

Therapeutically Equivalent means having essentially the same efficacy

and adverse effect profile.


2013 Plan Year – Rev. 12/3/2012

Urgent Care Center means an Alternate Facility that provides care or

treatment of an acute medical problem that requires prompt

professional attention but is not life-threatening, for example, a sprain,

severe earache, and nausea or migraine headache.

sprint consumer access medical plan

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